Men who have sex with men in Great Britain: comparing methods and estimates from probability and convenience sample surveys

Sexual Health Needs Among Men Who Engage in Transactional Sex with Men in the UK

Men who engage in transactional sex with men (MTSM) are a high-risk population for HIV and other sexually transmitted infections. Epidemiological data have so far included them in the broad category of men who have sex with men (MSM), while research on transactional sex typically focused on female sex workers. The internet has substantially changed sex work practices and earlier findings concerning the sexual health needs of MTSM may no longer be applicable. We analyzed quantitative data from MSM based in the UK (n = 11629) taking part in the European MSM Internet Survey (EMIS-2017). Compared to non-MTSM, MTSM (n = 230; 2%) were younger, more likely to self-identify as an ethnic minority, be single, have lower education levels, struggle financially, and-controlling for age-more likely to be living with diagnosed HIV. Commonly unmet needs among all MSM were a lack of confidence in accessing HIV post-exposure prophylaxis, uncertainty about HIV status, and ignorance of where to access hepatitis vaccinations. Compared with other MSM, MTSM were notably less satisfied with the safety of their sexual practices, less confident in their ability to maintain sexual boundaries, and more likely to engage in risk because of absent precautionary resources. Given their greater opportunity for sexual risk, as well as fewer resources for negotiating safety, our findings suggest that services should prioritize MTSM in HIV prevention and sexual health promotion, including assertiveness and social skills training, in addition to knowledge-based education.

When awareness is not a barrier to PrEP uptake among men who have sex with men who are eligible for PrEP in France

Despite PrEP being available and free of charge in France, a gap remains between the estimated number of men who have sex with men (MSM) with high-risk exposure to HIV and the number of MSM PrEP users. The objective of this study is to identify factors associated with non-intention to use PrEP among PrEP-eligible and PrEP-aware MSM in France, "non-intenders".European MSM Internet Survey (EMIS)-2017 was a cross-sectional survey conducted among MSM concerning their HIV prevention needs. Logistic regression models were used to identify factors associated with "non-intenders".Compared to PrEP users, factors associated with non-intention to use PrEP were: age (aOR[95%CI] = 3.80[2.21;6.53]); not being vaccinated against hepatitis B (2.20[1.45;3.34]); self-efficacy (1.84[1.29;2.60]); lower knowledge about on-demand PrEP (11.48[7.37;17.87]) and daily PrEP (2.58[1.27;5.25]); not having a PrEP discussion at a hospital (12.39[8.90;17.27]) or at a community service/drop-in (4.93[3.48;6.97]); living in a department with few PrEP access points (1.70[1.10;2.63]).On-demand PrEP may meet the prevention needs of "non-intenders" who have lower HIV risk perception. Increasing communication from health providers and community health workers to all MSM is needed.

Understanding Motivations for Dating App Use Among Gay and Bisexual Men: Validation, Latent Profile Analysis, and Differences in Health Outcomes

While there has been a proliferation in gay dating app (GDA) use in China, research into their potential effects on health outcomes, particularly mental health outcomes, among gay and bisexual men is lacking. The motivations for GDA use are diverse, and understanding users' motivation profiles may provide a necessary starting point for exploring the heterogeneous effects of GDA use on health outcomes. A cross-sectional survey of the motivations for GDA use and other health outcome variables (i.e., condom use frequency, self-stigma, and subjective emptiness) was conducted among 366 Chinese gay and bisexual men. The results of exploration structure equation modeling indicate that the GDA Use Motivation Scale, with a four-factor first-order model, had strong psychometric properties. Then, latent profile analysis (LPA) based on the mean scores of four aspects of motivation was performed. The results of the LPA revealed the existence of four profiles: "Weak motivations" (30.9%), "Differentiated motivations" (17.8%), "Moderate motivations" (30.3%), and "Strong motivations" (21.0%). Differences in health outcomes among the motivation profiles were found by using the Bolck-Croon-Hagenaars approach. Overall, most participants (60.1%) tended to use condoms consistently, regardless of how strong their GDA use motivation was; however, stronger GDA use motivations were associated with higher levels of self-stigma and subjective emptiness. We call for more research to focus on the real needs behind and motivations for GDA use so that all such app users' voices can be heard, as well as to raise awareness about the potential health risks associated with GDA use among Chinese gay and bisexual men.

Assessment and determinants of depression and anxiety on a global sample of sexual and gender diverse people at high risk of HIV: a public health approach

BACKGROUND

Sexual and gender diverse people face intersecting factors affecting their well-being and livelihood. These include homophobic reactions, stigma or discrimination at the workplace and in healthcare facilities, economic vulnerability, lack of social support, and HIV. This study aimed to examine the association between such factors and symptoms of anxiety and depression among sexual and gender diverse people.

METHODS

This study is based on a sample of 108,389 gay, bisexual, queer and questioning men, and transfeminine people from 161 countries collected through a cross-sectional internet survey. We developed a multinomial logistic regression for each group to study the associations of the above factors at different severity scores for anxiety and depression symptoms.

RESULTS

Almost a third (30.3%) of the participants reported experiencing moderate to severe symptoms of anxiety and depression. Higher severity scores were found for transfeminine people (39%), and queer or questioning people (34.8%). Severe symptoms of anxiety and depression were strongly correlated with economic hardship for all groups. Compared to those who are HIV-negative, those living with HIV were more likely to report severe symptoms of anxiety and depression, and the highest score was among those who do not know their HIV status. Transfeminine people were the most exposed group, with more than 80% higher risk for those living with HIV suffering from anxiety and depression. Finally, homophobic reactions were strongly associated with anxiety and depression. The relative risk of severe anxiety and depression was 3.47 times higher for transfeminine people facing transphobic reactions than those with no symptoms. Moreover, anxiety and depression correlate with stigma or discrimination in the workplace and healthcare facilities.

CONCLUSIONS

The strong association between the severity of anxiety and depression, and socioeconomic inequality and HIV status highlights the need for concrete actions to meet the United Nations' pledge to end inequalities faced by communities and people affected by HIV. Moreover, the association between stigma or discrimination and anxiety and depression among sexual and gender diverse people is alarming. There is a need for bold structural public health interventions, particularly for transfeminine, queer and questioning people who represent three communities under the radar of national HIV programmes.

The health inequity and socioeconomic inequality faced by adolescent girls and women on the move living with or at high risk of HIV infection, during the COVID-19 pandemic in Nigeria

BACKGROUND

We assessed if women and girls on the move living with or at high risk of HIV faced increased health inequity and socioeconomic inequalities during the COVID-19 pandemic compared with other vulnerable women and girls.

METHODS

We used data collected through a survey conducted in Nigeria between June and October 2021. Women and girls living with or at risk of HIV were recruited voluntarily, using a combination of venue-based and snowball sampling. We performed multivariable logistic regression models per mobility and HIV status to determine associations between health inequity, socioeconomic inequalities and macrosocial characteristics.

FINDINGS

There were 3442 participants, of which 700 were on the move. We found no statistical difference between HIV-negative women and girls on the move and those not on the move. On the opposite, we found substantial differences in health inequity and socioeconomic inequalities between women and girls on the move living with HIV and those not on the move living with HIV. There are very strong associations between being a woman or girl on the move living with HIV and facing economic precarity (aOR 6.08, 95% CI 1.94 to 19.03), food insecurity (aOR 5.96, 95% CI 2.16 to 16.50) and experiencing more gender-based violence since COVID-19 started (aOR 5.61, 95% CI 3.01 to 10.47).

INTERPRETATION

Being a woman or girl on the move and living with HIV compound increased health and socioeconomic vulnerabilities. The COVID-19 crisis seems to have exacerbated inequalities and gender-based violence. These findings call for more feminist interventions to protect women on the move living with HIV during health crises.

Gradient of vaccine hesitancy among French men having sex with men: An electronic cross-sectional survey in 2022

In developed countries, vaccinations against hepatitis B (HBV), hepatitis A (HAV), and human papillomavirus (HPV) are often recommended to men who have sex with men (MSM) because of the risky sexual practices in which some engage. Vaccine coverage against these diseases is not optimal in France, probably due in part to vaccine hesitancy (VH). The overall aim of this survey among MSM was to estimate the prevalence of different grades of VH for these vaccines as well as of general VH (toward any vaccine). The specific objectives were to study the sociodemographic correlates of MSM specific and general VH and its association with vaccine uptake. A cross-sectional electronic survey (February-August 2022) collected information from 3,730 French MSM about their perceptions of HBV, HAV, and HPV and their related vaccines, to construct "specific VH" variables. Information about their past vaccination behaviors for any vaccine was used to construct a "general VH" variable, based on the World Health Organization definition. Almost 90% of MSM showed moderate or high specific VH for HBV, HAV, and/or HPV, and 54% general VH. A higher education level and comfortable financial situation were associated with lower grades of specific and general VH. Younger age was associated with less frequent specific VH and more frequent general VH. Specific VH, versus general, was more strongly associated with frequent self-reported non-vaccination against these three disease. Addressing their concerns about vaccines, improving their knowledge of vaccine-preventable sexually transmitted infections, and motivating them to get vaccinated are public health priorities.

Condom use and HIV testing among adults in Switzerland: repeated national cross-sectional surveys 2007, 2012, and 2017

BACKGROUND

Monitoring of HIV and sexually transmitted infection (STI) prevention is important for guiding national sexual health programmes for both the general population and key populations. The objectives of this study were to examine trends and patterns of condom use at last intercourse and lifetime HIV testing in 2007, 2012 and 2017 in Switzerland, and to explore factors associated with these behaviours in men and women with opposite-sex partners and with same sex partners.

METHODS

We analysed data from the 2007, 2012 and 2017 Swiss Health Survey. For each time point, outcome and population group, we conducted a descriptive analysis of weighted data and conducted multivariable logistic regression to obtain adjusted odds ratios (aOR) with 95% confidence intervals (CI) and compared outcomes between the timepoints.

RESULTS

In total, 46,320 people were interviewed: 21,847 men and 23,141 women, who reported having sex only with partners of the opposite sex, 633 men who reported sex with a male partner and 699 women who reported sex with a female partner. Among the three surveys the prevalence of condom did not change but varied from 22 to 26% of men and 15 to 21% in women with only opposite-sex partners (aOR men, 0.93, 95% CI 0.82, 1.06; women 0.98, 95% CI 0.86 to 1.11). In men with any same sex partner the prevalence of condom use was 40% in 2007, 33% in 2012 and 54% in 2017 (aOR 1.80, 95% CI 0.97, 3.34). In multivariable analysis, the factor most strongly associated with condom use was sex with an occasional partner at last intercourse. HIV testing ever increased across all three survey years in people with opposite sex partners: 2017 vs. 2007, aOR men with only opposite-sex partners 1.64 (95% CI 1.49, 1.82), women with only opposite-sex partners 1.67 (1.51, 1.85), men with any same sex partner 0.98 (0.49, 1.96), women with any same sex partner 1.31 (0.74, 2.30).

CONCLUSIONS

Monitoring of condom use, and HIV testing should continue and contribute to the development of the national sexual health programme. Stronger promotion of condoms for people with opposite-sex partners might be needed, since overall condom use at last intercourse has not changed since 2007.

Recreational and sexualised drug use among gay, bisexual, and other men who have sex with men (gbMSM) in Ireland-Findings from the European MSM internet survey (EMIS) 2017

BACKGROUND

Gay, bisexual, and other men who have sex with men (gbMSM) report a higher prevalence of drug use in comparison to the general male population. However, in Ireland, there is a paucity of literature regarding the prevalence of drug use and its determinants among gbMSM.

AIMS/OBJECTIVES

To quantify the prevalence of (i) recreational drug use (RDU) and (ii) sexualised drug use (SDU) among gbMSM in Ireland, and to identify the factors associated with these drug use practices.

METHODS

The European MSM Internet Survey (EMIS) 2017 was an online, anonymous, internationally-promoted questionnaire. Two binary outcomes were included in our analyses: (1) RDU and (2) SDU in the previous year. Multivariable-adjusted logistic regression explored factors associated with these outcomes, and all independent covariates were adjusted for one another.

RESULTS

Among gbMSM without HIV (n = 1,898), 40.9% and 13.1% engaged in RDU and SDU in the previous year, respectively. Among diagnosed-positive gbMSM (n = 141), the past-year respective prevalence estimates were 51.8% and 26.2%. Increased odds of RDU were observed among gbMSM who were younger (vs. 40+ years) (18-24 years; AOR 2.96, 95% CI 2.05-4.28, 25-39 years; AOR 1.66, 95% CI 1.27-2.16), lived in Dublin (vs. elsewhere) (AOR 1.47, 95% CI 1.17-1.83), and engaged in condomless anal intercourse (CAI) in the previous year (vs. none) (1-2 partners; AOR 1.79, 95% CI 1.34-2.38, 6+ partners; AOR 1.79, 95% CI 1.18-2.71). Greater odds of SDU were identified among those who lived in Dublin (vs. elsewhere) (AOR 1.50, 95% CI 1.07-2.10), and engaged in CAI (vs. none) (1-2 partners; AOR 3.16, 95% CI 2.05-4.88, 3-5 partners; AOR 2.50, 95% CI 1.47-4.26, and 6+ partners; AOR 3.79, 95% CI 2.23-6.43).

CONCLUSION

GbMSM report a high prevalence of drug use in Ireland. Targeted interventions, including harm reduction campaigns, may be needed to support healthier drug use choices among this community.

The potential public health impact of adolescent 4CMenB vaccination on Neisseria gonorrhoeae infection in England: a modelling study

INTRODUCTION

Diagnoses of gonorrhoea in England rose by 26% between 2018 and 2019. Recent evidence that a vaccine against meningococcal B disease currently offered to infants in the UK (4CMenB) could additionally protect (with 31% efficacy) against gonorrhoea has led to renewed hope for a vaccine. A Phase 2 proof-of-concept trial of 4CMenB vaccination against gonorrhoea in adults is currently underway.

OBJECTIVES

To investigate the potential public health impact of adolescent gonorrhoea vaccination in England, considering different implementation strategies.

METHODS

We developed a deterministic transmission-dynamic model of gonorrhoea infection among heterosexual 13-64-year-olds stratified by age, sex and sexual activity. We explored the impact of a National Immunisation Programme (NIP) among 14-year-olds for a vaccine with 31% efficacy, 6 years' duration of protection, and 85% uptake. We also explored how impact might change for varying efficacy (20-50%) and uptake (75-95%), the addition of a catch-up programme, the use of boosters, and varying duration of protection.

RESULTS

An NIP against gonorrhoea could lead to 50,000 (95% credible interval, CrI 31,000-80,000) and 849,000 (95%CrI 476,000-1,568,000) gonorrhoea infections being averted over 10 and 70 years, respectively, in England, for a vaccine with 31% efficacy and 85% uptake. This is equivalent to 25% (95%CrI 17-33%) of heterosexual infections being averted over 70 years. Vaccine impact is predicted to increase over time and be greatest among 13-18-year-olds (39% of infections 95%CrI 31-49% averted) over 70 years. Varying vaccine efficacy and duration of protection had a noticeable effect on impact. Catch-up and booster vaccination increased the short- and long-term impact, respectively.

CONCLUSIONS

A partially-effective vaccine against gonorrhoea infection, delivered to 14-year-olds alongside the MenACWY vaccine, could have an important population impact on gonorrhoea. Catch-up and booster vaccination could be considered alongside cohort vaccination to increase impact.

Health Literacy as a Mediator of the Relationship Between Socioeconomic Position and Pre-Exposure Prophylaxis Uptake Among Men Who Have Sex with Men Living in France

BACKGROUND

In recent decades, several research studies have mentioned a potential mediating effect of health literacy (HL) on the relationship between socioeconomic position and health prevention behaviors. However, no study to date has investigated this hypothesis on HIV prevention behaviors.

OBJECTIVE

The present study aimed to evaluate whether HL mediates the relationship between socioeconomic status (SES) and pre-exposure prophylaxis (PrEP) uptake in men who have sex with men (MSM).

METHODS

The study is based on data collected in the Enquête Rapport au Sexe [report to sex] 2019 survey, an anonymous, self-administered online cross-sectional survey in France conducted between February 16, 2019 and March 31, 2019. Data on education level and perceived financial situation were used as measures of SES, whereas HL was assessed from the Health Literacy Questionnaire's "ability to actively engage with health care providers" scale. Mediation analyses were performed with a model-based causal moderated mediation analysis package in R software. Analyses were adjusted for age, place of residence, marital status, and social support.

KEY RESULTS

The study sample included 13,629 MSM. Median age was 32 years. The majority had an education level higher than upper secondary school (78%) and an adequate HL level (73%). Almost two-thirds perceived their financial situation as comfortable (62%). Overall, PrEP uptake was low (9.5%). The analyses did not show a mediating effect of HL on the relationship between education and PrEP uptake. However, a total mediation effect of HL was observed on the relationship between perceived financial situation and uptake.

CONCLUSIONS

In the context of PrEP uptake, MSM ability to actively engage with health care providers may offset the effect of a difficult financial situation. In the current French context, where PrEP is now also available in general practitioner settings, this result could inform the development of training and support policies for health professionals and the way in which sexual health issues are addressed in consultations. [HLRP: Health Literacy Research and Practice. 2023;7(1):e61-e70.].

Latin American Internet Survey for Men who have Sex with Men (LAMIS-2018): Design, methods and implementation

Despite men-who-have-sex-with-men (MSM) from Latin America (LA) are still a vulnerable population for known health-related conditions and social problems, availability of comparable data across LA countries for assessment and monitoring purposes is limited. The objective of this article is to present the study design and the questionnaire of LAMIS-2018 (Latin America MSM Internet Survey), its recruitment strategy, rates and sources by country, and the lessons learned from its implementation. LAMIS-2018 was a cross-sectional, internet-based survey targeting MSM living in 18 LA countries (Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Uruguay, and Venezuela) that gathered data about sexual behaviors, HIV/STI and viral hepatitis knowledge, prophylactic use of antiretrovirals, psychosocial health, and access to sexual health services. The survey went online for four months and was available in three languages (Spanish, Portuguese, and Dutch). Promotion was carried out using dating apps, websites, social networks, and by community-based and academic organizations of each participating country directly in gay venues and in their own premises. Overall, 64,655 MSM participated in LAMIS-2018. Dating apps and websites were the most important recruitment source in most countries, except for Honduras, Nicaragua, and Suriname, where community-based organizations recruited most of the participants. Beyond the LAMIS-2018 implementation description, we highlight the feasibility of such a study in this context, based on the collaboration between community-based and academic organizations to obtain a large sample of MSM in the region. LAMIS-2018 data will contribute to identify determinants of risk behaviors and prevention needs of vulnerable MSM populations in each country of the region.

Sexualized drug use among men who have sex with men in Madrid and Barcelona: The gateway to new drug use?

This original study compares the prevalences of drug use for any purpose and for sexualized drug use (SDU) among MSM. It also describes relevant characteristics of first SDU, analyzes to what extent SDU has been the first experience (the gateway) with different drugs by age and explores the correlates of SDU. Study participants included 2,919 HIV-negative MSM attending four HIV/STI diagnosis services in Madrid and Barcelona. They answered an online, self-administered questionnaire. Poisson regression models with robust variance were used. About 81.4% had ever used any drug, and 71.9% had done so in the last-12-months, while 56% had ever engaged in SDU, and 50% had done so in the last-12-months. Participants under 25 years old had the lowest prevalences of SDU, and the 25-39 age group the highest, except for Viagra, which was higher among those over age 40. The most frequently used drugs for first SDU were poppers (53.6%), cannabis (19.6%) and Viagra (12.2%). These drugs were also the most ever consumed for SDU. Among sexualized users, methamphetamine (78.3%) and Mephedrone (75.4%) were used always/most of the times for sex in the last-12-months. Around 72.2% of Mephedrone sexualized users and 69.6% of Methamphetamine vs 23.1% of ecstasy users' first consumption of these drugs involved use for sex. These drugs were provided to them free where they have sex for 66.8, 79.1, and 31.9%, respectively. On that occasion, 8.1% of Mephedrone, 6.8% of Methamphetamine and 18.4% of ecstasy users had sex only with steady partner; with 50.2, 56.2, and 26.2% respectively using a condom with any partner. SDU in the first use was associated with similar variables for recreational and chemsex drugs. The highest prevalence ratios were for having ever been penetrated by >20 men and having ever injected drugs. It can be concluded that the prevalence of SDU was more than half of the prevalence for any purpose. Thus SDU was the gateway to use for many drugs in an important proportion of users, who frequently consumed drugs that were free and had condomless anal sex with occasional and multiple partners. These circumstances were much more common for chemsex than for recreational drugs.

Social and behavioural determinants of syphilis: Modelling based on repeated cross-sectional surveys from 2010 and 2017 among 278,256 men who have sex with men in 31 European countries

Background

Syphilis case notifications among men-who-have-sex-with-men (MSM) have increased markedly over the past two decades in Europe. We tested several potential factors for this resurgence.

Methods

Self-reported data from two cross-sectional waves of the European MSM Internet Survey (EMIS-2010 and EMIS-2017, N = 278,256 participants living in 31 European countries) were used to fit multivariable hierarchical logistic regression models designed to evaluate potential social, behavioural, and interventional determinants of syphilis diagnosis. Additional multivariable hierarchical negative binomial models investigated determinants of the number of non-steady male condomless anal intercourse (CAI) partners. We tested the hypothesis that more CAI and syphilis-screening are associated with syphilis resurgence, both linked to use of pre-exposure prophylaxis (PrEP).

Findings

Between 2010 and 2017, incidence of syphilis diagnosis in the previous 12 months rose from 2.33% (95%CI: 2.26–2.40) of respondents reporting a syphilis diagnosis in 2010 compared with 4.54% (95%CI: 4.42–4.66) in 2017. Major factors contributing to syphilis diagnosis were living with diagnosed HIV (adjusted odds ratio (aOR) 2.67, 95%CI: 2.32–3.07), each additional non-steady male CAI partner (aOR 1.01, 95%CI: 1.01–1.01), recency of STI-screening (previous month vs no screening, aOR 25.76, 95%CI: 18.23–36.41), selling sex (aOR 1.45, 95%CI: 1.27–1.65), and PrEP use (aOR 3.02, 95%CI: 2.30–3.96). Living with diagnosed HIV (adjusted incidence rate ratio (aIRR) 3.91, 95%CI: 3.77–4.05), selling sex (aIRR 4.39, 95%CI: 4.19–4.59), and PrEP use (aIRR 5.82, 95%CI: 5.29–6.41) were associated with a higher number of non-steady male CAI partners. The association between PrEP use and increased chance of syphilis diagnosis was mediated by STI-screening recency and number of non-steady male CAI partners, both substantially higher in 2017 compared to 2010.

Interpretation

Syphilis cases are concentrated in three MSM population groups: HIV-diagnosed, PrEP users, and sex workers. Behavioural and interventional changes, particularly more non-steady male CAI partners and recency of STI-screening, are major contributing factors for increasing syphilis diagnoses among MSM in Europe.

Funding

European Centre for Disease Prevention and Control.

Sexual happiness and satisfaction with sexual safety among German trans men who have sex with men: results from EMIS-2017

INTRODUCTION

The population of men-who-have-sex-with-men (MSM) includes people who are on the masculine spectrum but were assigned female at birth (AFAB), that is trans MSM. This study aims to identify current circumstances regarding sexual happiness and safety among German trans MSM. To date, there is no health information about trans MSM in Germany, limiting the ability of MSM sexual health programmes to meet their needs.

METHODS

Data were used from the European MSM Internet Survey (EMIS-2017), where people identifying as men and/or trans men were recruited through dating apps for MSM, community websites and social media to participate in an online survey. We analysed parameters on sexual happiness and satisfaction with sexual safety among Germany-based trans MSM and compared those to outcomes of MSM assigned male at birth (cis MSM) living in Germany using descriptive methods and logistic regression models adjusting for age.

RESULTS

In total, 23,001 participants from Germany were included, of which 122 (0.5%) indicated to be AFAB (i.e. trans MSM). Trans MSM were markedly younger than cis participants (median age: 28.5 vs. 39 years). Trans MSM more often reported being unhappy with their current sex life (adjusted odds ratio [aOR] = 1.82, 95% CI 1.24-2.67), had higher odds of disagreeing with the statements "the sex I have is always as safe as I want" ([aOR] = 1.82, 95% CI 1.24-2.67) and "I find it easy to say no to sex that I don't want" ([aOR] = 1.80, 95% CI 1.18-2.77). Trans MSM were more likely to not be living comfortably financially ([aOR] = 2.43, 95% CI 1.60-3.67) and to be living with severe anxiety and/or depression ([aOR] = 3.90, 95% CI 2.22-6.83). Trans MSM were less likely to have ever tested for HIV ([aOR] = 0.63, 95% CI 0.43-0.93).

CONCLUSIONS

Sexual happiness, control of sexual boundaries, satisfaction with sexual safety, financial security, mental wellbeing and HIV testing were all lower in German trans MSM compared with cis MSM. Tailored sexual health interventions, contextualized with regard to needs and vulnerabilities, could address this inequality.

Comparison of the Influence of Internalized Homonegativity on Sexual Risk Behavior of Men Who Have Sex with Men in Spain and Turkey

Objectives: This study aimed to understand how the association between internalized homonegativity (IH) and sexual risk behavior differed in Spain (N = 3,336) and Turkey (N = 550). Methods: We used multigroup structural equation modeling. Results: HIV and pre-exposure prophylaxis (PrEP) knowledge mediated the relationship between IH and sexual risk behavior among MSM in Spain, but not among men in Turkey. Higher HIV/PrEP knowledge was associated with higher sexual risk behavior among MSM in Spain, while among MSM in Turkey the association was in the opposite direction. Conclusions: The meaning of safe-sex may differ across contexts, and this should be taken into consideration when tailoring HIV prevention programs.

Awareness of, Willingness to Take PrEP and Its Actual Use Among Belgian MSM at High Risk of HIV Infection: Secondary Analysis of the Belgian European MSM Internet Survey

We examined PrEP awareness, willingness to take it and early PrEP use among men who have sex with men (MSM) at increased risk of HIV acquisition in Belgium. This analysis of the Belgian EMIS online data of 2017-2018 adopts a cascade approach, with the following steps quantified as conditional probabilities: being eligible for, aware of, willing to take PrEP, and PrEP use. One out of three MSM was eligible to use PrEP according to the operationalized Belgian reimbursement criteria. PrEP awareness was lower among socioeconomically vulnerable MSM, MSM living outside large cities, MSM who were less open about their sexuality and those who did not identify as gay or homosexual. A lack of PrEP knowledge, a higher self-efficacy regarding safe sex, having a steady partner and reporting more symptoms of depression were related to unwillingness to use PrEP. Among those willing to take PrEP, less than one third were actually using PrEP. Not using PrEP was associated with living in small cities and experiencing financial problems.

Exploring community enabling factors associated with recent HIV testing in a regional sample of gay, bisexual, and other men who have sex with men

HIV testing and diagnosis are the gateway into treatment and eventual viral suppression. With gay, bisexual, and other men who have sex with men (GBMSM) persistently over-representing new HIV diagnoses in Canada, combined with the evolving nature of community social connection, an exploration of factors associated with recent HIV testing is warranted. As most studies of GBMSM rely on samples obtained from larger metropolitan regions, examining HIV testing from an under-researched region is necessary. With data collected from an online survey of LGBTQ+ persons 16 or older living, working, or residing in the Region of Waterloo, Ontario, Canada, we used multinomial logistic regression to explore socio-demographic, behavioural, and psychosocial factors associated with recent HIV testing for GBMSM. In the final multivariate multinomial logistic regression model: sense of belonging was associated with more recently testing, as was having an increasing proportion of LGBT friends, app use to find sex partners in the past 12 months, access to the local AIDS service organization, and general sense of belonging to local community, among other. This analysis highlights the continued importance of enabling and need factors when accessing testing, and suggests areas for further testing promotion in physical and virtual spaces frequented by GBMSM.

Predictors of Uncertainty and Unwillingness to Receive the COVID-19 Vaccine in Men Who Have Sex with Men in France

The development of vaccines against COVID-19 has given hope to populations. Public acceptability of vaccination is a major driver in containing the disease. However, in marginalized and stigmatized populations, uncertainty and unwillingness may be a challenge. This study aimed to analyze the factors associated with uncertainty and unwillingness to vaccinate against COVID-19 in men who have sex with men (MSM) living in France. The data used came from Rapport au Sexe (ERAS) 2021, a voluntary, cross-sectional, anonymous, self-administered, online survey conducted from 26 February to 11 April 2021. Among the 15,426 respondents included in the analysis, 60.5% were willing to vaccinate (these included persons already vaccinated), 17.5% were not, and 22% were uncertain. Factors independently associated with uncertainty and unwillingness were lower education level, low health literacy level, financial hardship, being under 30 years of age, and living in a rural area. HIV-positive MSM were less likely to report vaccination uncertainty and unwillingness than HIV-negative MSM and those with unknown serostatus. Although more impacted by COVID-19, socioeconomically vulnerable MSM were the sub-group most unwilling to vaccinate. To improve acceptability of COVID-19 vaccination in MSM, policy makers and researchers must increase access to and understanding of medical information by considering the general public's health literacy when developing information sources. Moreover, a dedicated global care approach, which ensures these populations can be reached, is necessary.

Navigating the LGB Data Landscape: A Review of Appropriate Secondary Data Sources for Sexuality and Substance Use Research in the UK

Research has found that sexual minority individuals are more likely to experience health inequalities and have higher rates of substance use compared with their heterosexual counterparts. This association between sexuality and health outcomes is increasingly being explored using quantitative methodologies within the context of public health, psychology and health geography. Much of this research, however, has relied on primary data, despite the wide availability of secondary sources, mainly survey data, collecting information on sexuality and different types of health outcomes and health risk behaviours, such as substance use. This study reviewed recent surveys in the UK that are appropriate for exploring topics related to LGB populations and substance use behaviours. We carried out a narrative review of secondary data sources in the UK to assess the accessibility and suitability of secondary sources for sexuality and substance use research. We identified eight cross-sectional and two longitudinal surveys that contained both sexuality and substance use data. We summarised the possible applications of each survey and the scope of questions within sexuality and substance use research that could be addressed by each survey. The identification of appropriate surveys in this review can allow researchers to extend the use of secondary data sources in the UK to examine substance use inequalities between sexuality groups, further advancing this key topic.

How well do covariates perform when adjusting for sampling bias in online COVID-19 research? Insights from multiverse analyses

COVID-19 research has relied heavily on convenience-based samples, which-though often necessary-are susceptible to important sampling biases. We begin with a theoretical overview and introduction to the dynamics that underlie sampling bias. We then empirically examine sampling bias in online COVID-19 surveys and evaluate the degree to which common statistical adjustments for demographic covariates successfully attenuate such bias. This registered study analysed responses to identical questions from three convenience and three largely representative samples (total N = 13,731) collected online in Canada within the International COVID-19 Awareness and Responses Evaluation Study ( www.icarestudy.com ). We compared samples on 11 behavioural and psychological outcomes (e.g., adherence to COVID-19 prevention measures, vaccine intentions) across three time points and employed multiverse-style analyses to examine how 512 combinations of demographic covariates (e.g., sex, age, education, income, ethnicity) impacted sampling discrepancies on these outcomes. Significant discrepancies emerged between samples on 73% of outcomes. Participants in the convenience samples held more positive thoughts towards and engaged in more COVID-19 prevention behaviours. Covariates attenuated sampling differences in only 55% of cases and increased differences in 45%. No covariate performed reliably well. Our results suggest that online convenience samples may display more positive dispositions towards COVID-19 prevention behaviours being studied than would samples drawn using more representative means. Adjusting results for demographic covariates frequently increased rather than decreased bias, suggesting that researchers should be cautious when interpreting adjusted findings. Using multiverse-style analyses as extended sensitivity analyses is recommended.

Comparison of Polydrug Use Prevalences and Typologies between Men Who Have Sex with Men and General Population Men, in Madrid and Barcelona

This study compares the prevalence of drug use and the typologies of polydrug use (PDU) in men who have sex with men (MSM) and general population men (GPM). Participants were men aged 16–64, living in the provinces of Madrid and Barcelona: 1720 were recruited in a GPM survey, and 2658 were HIV-negative MSM from HIV/STIs diagnosis services. Lifetime and last-year prevalence of drug use and prevalence ratios (PRs) of MSM to GPM for the different drugs were calculated using Poisson regression. Latent class analysis (LCA) was performed to identify typologies of PDU. Lifetime use of the drugs considered was higher in MSM, and even higher for drug use in the last-year: PRs for cannabis, hallucinogens and cocaine ranged from 2–5; for amphetamine, ecstasy and methamphetamine 12–16; and above 60 for ketamine, GHB/GBL, inhalants and mephedrone. In the LCA for lifetime PDU four classes arose from the GPM (No-PDU (79.6%); Conventional PDU (13.8%); Intensive conventional PDU (4.9%); Heavy PDU (1.8%)) and four among MSM (No-PDU (57.7%); Conventional PDU plus poppers (18.8%); PDU preferring chemsex drugs (6.4%); Heavy PDU (17.2%)). For PDU during the last-year, three classes arose in the GPM: No-PDU (94.7%); Conventional PDU (4.3%); Heavy PDU (0.9%). For MSM, we identified four classes: No-PDU (64.7%); Conventional PDU plus poppers (15.6%); PDU preferring chemsex drugs (6.2%); Heavy PDU (13.5%). MSM should be considered a priority group for the prevention of the use of all drugs but the heterogeneity of PDU typologies regarding users’ preference towards conventional and/or sexualised drugs needs to be taken into account.

[The European MSM Internet Survey as a basis for prevention work in Germany for men who have sex with men]

Hintergrund

Sexuelle Minderheiten sind in hohem Maße anfällig für sexuell übertragbare Infektionen (STI), psychische Probleme wie Depressionen und Suizidalität sowie für gesundheitliche und soziale Probleme, die mit Substanzkonsum assoziiert sind.

Ziel der Arbeit

Wir beschreiben ausgewählte Ergebnisse aus dem Europäischen MSM Internet Survey (EMIS) 2017, eine der größten Onlinebefragungen von Männern, die Sex mit Männern haben (MSM), und diskutieren deren Implikationen für die Prävention in Deutschland.

Material und Methoden

Das übergeordnete Ziel von EMIS-2017 war es, Daten für die Planung von HIV- und STI-Präventions- und -Behandlungsprogrammen zu erheben. Die Zielpopulation waren in Europa lebende MSM. Der Fragebogen enthielt Fragen zu Demografie, Morbiditäten, Verhalten, Bedarfen und Interventionen. Die deutschen Teilnehmer wurden von 10/2017 bis 01/2018 vor allem über 2 große Onlinedatingplattformen rekrutiert.

Ergebnisse und Diskussion

EMIS-2017 zeigt, dass MSM stark von psychischen Belastungen und STI betroffen sind. Jüngere MSM leiden verstärkt unter depressiven Störungen und Suizidalität, während bei älteren MSM der Konsum von Alkohol und anderen psychoaktiven Substanzen bedeutsam ist.

MSM sind von STI stärker betroffen als Heterosexuelle. Viele STI verursachen keine oder nur untypische Beschwerden, daher wird ein Screening auf der Basis einer Risikoeinschätzung favorisiert. Für einen Teil der STI gibt es bislang keine medizinischen und/oder Public-Health-Erkenntnisse, die für eine Behandlung asymptomatischer Infektionen sprechen. EMIS-2017 identifizierte Bedarfe nach Untergruppen in Bezug auf Wissenslücken zu HIV-Post- und HIV-Präexpositionsprophylaxe (PEP, PrEP), Erreichbarkeit durch Informations- und Präventionsangebote sowie unzureichende Nutzung dieser Angebote.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00103-021-03429-3) enthalten.

Evidence of changing sexual behaviours and clinical attendance patterns, alongside increasing diagnoses of STIs in MSM and TPSM

Background

Due to rising numbers of STI diagnosis and increasing prevalence of antimicrobial resistance, we explored trends in STI testing frequency and diagnoses, alongside sexual decision making and attitudes concerning condom use and HIV pre-exposure prophylaxis (PrEP) at a large urban UK sexual health clinic.

Methods

We examined 66 528 electronic patient records covering 40 321 attendees between 2016 and 2019, 3977 of whom were men who have sex with men or trans persons who have sex with men (MSM/TPSM). We also explored responses from MSM/TPSM attendees sent an electronic questionnaire between November 2018 and 2019 (n=1975) examining behaviours/attitudes towards PrEP. We measured trends in STI diagnoses and sexual behaviours including condomless anal intercourse (CAI), using linear and logistic regression analyses.

Results

Tests resulting in gonorrhoea, chlamydia or syphilis diagnoses increased among MSM/TPSM from 13.5% to 18.5% between 2016 and 2019 (p<0.001). The average MSM/TPSM STI testing frequency increased from 1.5/person/year to 2.1/person/year (p=0.017). Gay MSM/TPSM had the highest proportions of attendances resulting in diagnoses, increasing from 15.1% to 19.6% between 2016 and 2019 (p<0.001) compared with bisexual/other MSM/TPSM increasing from 6.9% to 14.5% (p<0.001), alongside smaller but significant increases in non-MSM/TPSM from 5.9% to 7.7% (p<0.001).

The proportion of MSM/TPSM clinic attendees reporting CAI in the previous 3 months prior to at least one appointment in a given year increased significantly from 40.6% to 45.5% between 2016 and 2019 (p<0.0001) and average number of partners from 3.8 to 4.5 (p=0.002). Of 617 eligible questionnaire responses, 339/578 (58.7%) HIV-negative and 29/39 (74.4%) HIV-positive MSM/TPSM indicated they would be more likely to have CAI with someone on PrEP versus not on PrEP. 358/578 (61.9%) HIV-negative respondents said that PrEP use would make them more likely to have CAI with HIV-negative partners.

Conclusion

Rising numbers of STI diagnoses among MSM/TPSM are not attributable to increased testing alone. Increased CAI and number of partners may be attributable to evolving sexual decision making among PrEP users and their partners. Proportionally, bisexual/other MSM/TPSM have the steepest increase in STI diagnoses.

Sexualized drug injection among men who have sex with men in Madrid and Barcelona as the first episode of drug injecting

BACKGROUND

We estimate the prevalence of drug injection, the variables associated with having ever injected and the proportion of ever injectors whose first drug injection was for having sex; we describe the first drug injection episode, analyze the drugs most frequently injected and estimate the prevalence of risky injecting behaviors.

METHODS

The participants were 3387 MSM without a previous HIV diagnosis attending four HIV/STI diagnosis services in Madrid and Barcelona. Lifetime prevalence and prevalence ratios (PRs) by different factors were calculated using Poisson regression models with robust variance. We compared the characteristics of first drug injection episode, lifetime injection and risky injecting behaviors of those whose first injection was for sex (FIS) with those whose was not (non-FIS).

RESULTS

Lifetime prevalence of injection was 2.1% (CI 1.7-2.7). In the multivariate analysis, it was strongly associated with having been penetrated by more than five men in the last 12 months (aPR = 10.4; CI 2.5-43.4) and having met most of their partners at private parties (aPR = 7.5; CI 4.5-12.3), and less strongly with other factors. Of those who had ever injected drugs, 81.9% injected for sex the first time they injected drugs (FIS). At first injection, FIS participants had a mean age of 31 years, 62.7% used mephedrone and 32.2% methamphetamine on that occasion. Of this FIS group 39.0% had ever shared drugs or equipment and 82.6% had always shared for sex. Some 30.8% of non-FIS reported having also injected drugs for sex later on.

CONCLUSIONS

Only two out of a hundred had ever injected, most to have sex and with frequent drug or injecting equipment sharing. Injecting for sex is the most common first episode of drug injection and is the most efficient risky behavior for the transmission of HIV, hepatitis B or C and other blood-borne infections. MSM participating in private parties should be considered a priority group for prevention policies.

Injection of Anabolic Steroids in Men Who Had Sex with Men in Madrid and Barcelona: Prevalence Correlates and Role as a Risk Factor for Transmitted Infections

This study describes the prevalence of anabolic-androgenic steroid (AAS) injection, their main correlates, and the prevalence of specific AAS injection risk behaviours among men who have sex with men (MSM), an area insufficiently addressed in scientific research. Participants were HIV-negative MSM attending four HIV/STI diagnosis services: two clinics and two community programmes in Madrid and Barcelona. Participants answered an online self-administered questionnaire. Crude and adjusted lifetime prevalence and prevalence ratios (PRs) were calculated by different factors and using Poisson regression models with robust variance. Of the 3510 participants, 6.1% (95% CI: 5.3-6.9) had injected AAS before and 3.5% (95% CI: 2.9-4.2) had done so in the last 12 months. In the multivariate analysis, AAS injection was independently associated with being over 40 years old (aPR = 3.6; 95% CI: 2.0-6.5) and being born in Latin America (aPR = 2.5; 95% CI:1.9-3.4), and was less strongly associated (aPRs of around two) with having been recruited into STI clinics, having ever been paid for sex before, injected drugs, used drugs for sex, having been diagnosed with an STI before, and having been diagnosed with HIV at the recruitment consultation. Only three participants, 1.4%, of those who had injected AAS before had shared AAS or equipment for preparation or injecting before. Conclusions: In contrast to drugs, AAS injecting behaviours do not play a relevant, direct role in the transmission of blood-borne infections among MSM. However, AAS injectors have a higher prevalence of sexual risk behaviours. These findings should be confirmed using new studies that employ other sampling procedures.

Sexual Health Studies in Gay and Lesbian People: A Critical Review of the Literature

BACKGROUND

The subject of gay and lesbian sexual health seems to be highly understudied, at least partially due to general limitations inherent in the studies of sexuality as well as heteronormative bias and difficulties in reaching out to these populations.

AIM

To critically review the studies on gay and lesbian sexual health in order to identify the existing gaps and biases in the scope and general construction of the published research.

METHODS

The dataset comprised 556 peer-reviewed articles identified through Medline search. Key studies characteristics were extracted according to the codebook developed for this study and analyzed descriptively.

OUTCOMES

The outcomes included: research methodology, study design, sampling, research topic and diversity inclusion in studied populations.

RESULTS

The majority of the studies were quantitative (70.5%), cross-sectional (83.6%) and used convenience sampling (83.2%). Most papers focused on HIV/STI risk behaviors, vulnerabilities and risk navigation (26.3%). The least often found topic captured the sexual function of gay and lesbian participants in older age (0.5%). Over 68% of papers relied on male samples and studies on female-only samples comprised less than 13%. Most studies did not recruit a specific age group (77.7%) and included information about ethnicity of study participants (62%). Information about education (58.7%) or other indicators of socioeconomic status (52.8%) was less often reported.

CLINICAL TRANSLATION

The methodological limitations of prevailing study designs, sampling procedures and the composition of samples, as well as extensive areas of omission confine the clinical utility of existing research.

STRENGTHS & LIMITATIONS

This study offers critical insights into the most significant challenges associated with studies on gay and lesbian sexual health. Medline-only database search, the inclusion of English-written papers exclusively and limited scope (gay and lesbian sexuality only) of the review constitute the most significant limitations.

CONCLUSIONS

Gay and lesbian sexual health is an understudied field characterized by primary focus on HIV/STI and paucity of higher quality research including diverse subpopulations. Mijas M, Grabski B, Blukacz M, et al. Sexual Health Studies in Gay and Lesbian People: A Critical Review of the Literature. J Sex Med 2021;XXX:XXX-XXX.

Key Findings from the European Men-Who-Have-Sex-With-Men Internet Survey in Greece

The European Men-Who-Have-Sex-With-Men Internet Survey (EMIS-2017) is an international survey for men who have sex with men (MSM) designed to measure the level and distribution of four dimensions: (a) sexual health outcomes, (b) risk and precaution behaviors, (c) health promotion needs, and (d) coverage/uptake of interventions. The aim of the current work is to provide an overview of key demographics and findings for MSM in Greece covering the abovementioned dimensions of EMIS-2017, especially regarding HIV. Overall, 2909 men met the inclusion criteria for the analysis. The participants' age ranged between 15 and 74 years old (median 35 years). According to the descriptive analysis, 14.4% of the participants reported moderate and 8.9% severe anxiety and depression. The self-reported HIV prevalence was 11%. A high number of participants had non-steady male partners (74%, n = 2153). The number of non-steady intercourse partners in the last 12 months was over two for about 61.5% (n = 1321) of the participants. A very small number of participants had ever tried to get pre-exposure prophylaxis (PrEP) (2.2%, n = 63), and 41.2% of the participants (n = 1199) were unaware of PrEP. About half of the participants (51.6%, n = 1501) did not know that vaccination against both hepatitis A and B viruses is recommended for MSM. The results of EMIS-2017 identify important needs and can help policy making and prevention planning.

Factors associated with methamphetamine dependency among men who have sex with men engaging in chemsex: Findings from the COMeT study in Taiwan

BACKGROUND

Sexualized drug use or "chemsex" in Taiwan commonly incorporates the use of methamphetamine. Our study aimed to assess the extent of severity of dependence of methamphetamine among MSM in Taiwan as well as motivations for engagement in chemsex.

METHODS

Direct messages were sent to users of a large MSM social networking application in Taiwan between November 2018 and January 2019. MSM who had at least one experience of using drugs during sex in the preceding 12 months were invited to complete an online survey that assessed their sexual behavior, substance use and motivations for engaging in chemsex. The Severity of Dependence Scale was used to assess methamphetamine dependency. Multivariable logistic regression was used to determine the factors associated with methamphetamine dependency.

RESULTS

From a total of 1906 responses, 517 had used methamphetamine in their lifetime and were included in the analysis. The majority (87.2%) used more than one substance when engaging in chemsex in the past six months, while a quarter reported injection of methamphetamine within the last six months. The most commonly reported motivations for participants to engage in chemsex were to have fun, for relaxation, and to increase the intensity of the sexual experience. Nearly half (46.0%) exhibited signs of methamphetamine dependency. Lower monthly income, injection of methamphetamine, ever feeling lonely in the past 3 months and concerns about their substance use expressed by others were significantly associated with methamphetamine dependency.

CONCLUSION

A high proportion of MSM population who engaged in chemsex were at risk of developing methamphetamine dependency. While motivations for engaging in chemsex were diverse and suggest potential for enhanced sexual experience for some, community health organization for gay men's health and healthcare providers should be vigilant at identifying the risk of methamphetamine dependency and provide in-time, brief intervention or referrals when needed.

Chemsex and diagnoses of syphilis, gonorrhoea and chlamydia among men who have sex with men in the UK: a multivariable prediction model using causal inference methodology

INTRODUCTION

In the last decade diagnoses of most STIs have risen among men who have sex with men (MSM). Although a significant proportion of this is likely due to increased STI screening, understanding the role of behavioural drivers remains critical. We measure the associations between stimulant use to enhance and prolong sexual experiences (chemsex) and bacterial STI diagnoses in UK MSM, individually considering HIV-diagnosed MSM, pre-exposure prophylaxis (PrEP) users and other MSM.

METHODS

We used the UK 2017-2018 European MSM Internet Survey data (n=9375). We constructed causal inference models using multivariable logistic regression, calculating adjusted OR (aOR) and 95% CI of the associations between participation in recent (≤12 months) exclusively dyadic or multipartner chemsex versus no chemsex and recent self-reported diagnoses of syphilis, gonorrhoea and chlamydia.

RESULTS

Among MSM with an HIV diagnosis, 25% of users indicated recent multipartner chemsex, vs 28% of PrEP users and 5% of other MSM. Adjusting for age, ethnicity, UK birth, cis-trans status, sexual identity, education, settlement size and relationship status, participation in recent multipartner chemsex versus no chemsex was associated with greater odds of recent syphilis, gonorrhoea and chlamydia diagnosis. aORs for recent syphilis, gonorrhoea and chlamydia diagnoses were 2.6 (95% CI 1.7 to 4.1), 3.9 (95% CI 2.6 to 5.8) and 2.9 (95% CI 1.9 to 4.3), respectively, in HIV-diagnosed MSM; 1.9 (95% CI 1.1 to 3.3), 2.9 (95% CI 2.0 to 4.2) and 1.9 (95% CI 1.3 to 2.8), respectively, in PrEP users; and 4.0 (95% CI 2.3 to 6.9), 2.7 (95% CI 1.9 to 3.8) and 2.3 (95% CI 1.6 to 3.4), respectively, in other MSM. Conversely, exclusively dyadic chemsex had no significant associations with bacterial STI diagnoses among HIV-diagnosed MSM, only gonorrhoea (aOR 2.4, 95% CI 1.2 to 4.7) among PrEP users and syphilis (aOR 2.8, 95% CI 1.4 to 5.6) among other MSM.

DISCUSSION

Multipartner chemsex may drive the association between chemsex and bacterial STI diagnoses and thus should be the focus of future tailored chemsex interventions. Additionally, PrEP acceptability among MSM and particularly chemsex participants has generated an emergent group suitable for such interventions.

The incorporation of HIV self-testing as an exclusive option among men who have sex with men in Spain: results of an online cross-sectional study

Background

We assessed to what extent HIV self-testing would be incorporated by men who have sex with men (MSM) with previous testing history as their exclusive testing option and describe what actions they would take in the case of obtaining a reactive self-test.

Methods

We conducted an online survey among Spanish resident MSM recruited mainly in gay dating apps and analyze 6171 ever tested individuals. We used Poisson regression to estimate factors associated with the incorporation of self-testing as the exclusive testing option. Among those who would incorporate self-testing as their exclusive option, we described actions taken if obtaining a reactive self-test by number of tests in the past.

Results

Nearly half of the participants (48.3%) were > =35 years old, 84.6% were born in Spain, 57.9% had attained a university degree, 55.1% lived in a municipality of ≤500.000 and 86.4% self-identified as homosexual. For 37.2%, self-testing would become their exclusive testing option. The incorporation of self-testing as the exclusive option increased with age 25–34 (PR:1.1, 95%CI:1.0–1.3), 35–44 (PR:1.3, 95%CI:1.2–1.5), 45–49 (PR:1.5, 95%CI:1.3–1.7) and > 50 (PR:1.5, 95%CI:1.3–1.8) and in those who reported unprotected anal intercourse (PR:1.1, 95%CI:1.0–1.2) or having paid for sex (PR:1.2, 95%CI:1.0–1.3) in the last 12 months. It was also associated with having had < 10 HIV test in the past (2–9 tests (PR:1.3, 95%CI:1.1–1.4); 1 test (PR:1.5, 95%CI:1.3–1.7)), and having been tested ≥2 years (PR:1.4, 95%CI:1.3–1.5) or between 1 and 2 years ago (PR:1.1, 95%CI:1.0–1.2). Of participants who would use self-testing exclusively 76.6% would confirm their result in case of obtaining a reactive self-test and only 6.1% wouldn’t know how to react. Only one individual expressed that he would do nothing at all.

Conclusion

HIV self-testing could become the exclusive testing option for more than a third of our participants. It was chosen as the exclusive option especially by older, at risk and under-tested MSM. Self-testing strategies need to especially consider the linkage to care process. In this sense, only a small fraction would not know how to react and virtually nobody reported taking no action if obtaining a reactive result.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09976-9.

Potential of HIV Self-Sampling to Increase Testing Frequency Among Gay, Bisexual, and Other Men Who Have Sex With Men, and the Role of Online Result Communication: Online Cross-Sectional Study

Background

Late HIV diagnosis remains frequent among the gay, bisexual, and other men who have sex with men (GBMSM) population across Europe. HIV self-sampling could help remove barriers and facilitate access to testing for this high-risk population.

Objective

We assessed the capacity of HIV self-sampling to increase the testing frequency among GBMSM living in Denmark, Germany, Greece, Portugal, Romania, and Spain, and evaluated the role of new technologies in the result communication phase.

Methods

We analyzed a convenience sample of 5019 GBMSM with prior HIV testing experience who were recruited during 2016 through gay dating websites. We estimated the proportion of GBMSM who reported that the availability of self-sampling would result in an increase of their current testing frequency. We constructed a Poisson regression model for each country to calculate prevalence ratios and 95% CIs of factors associated with an increase of testing frequency as a result of self-sampling availability.

Results

Overall, 59% (between country range 54.2%-77.2%) of the participants considered that they would test more frequently for HIV if self-sampling was available in their country. In the multivariate analysis, the increase of testing frequency as a result of self-sampling availability was independently associated with reporting a higher number of unprotected anal intercourse events in all countries except for Greece. Independent associations were also observed among GBMSM who were not open about their sex life in Germany, Greece, Portugal, and Spain; those with a lower number of previous HIV tests in Denmark, Greece, Portugal, and Spain; and for those that took their last test more than 3 months previously in Germany, Portugal, Romania, and Spain. In addition, 58.4% (range 40.5%-73.6%) of the participants indicated a preference for learning their result through one-way interaction methods, mainly via email (25.6%, range 16.8%-35.2%) and through a secure website (20.3%, range 7.3%-23.7%). Almost two thirds (65%) of GBMSM indicated preferring one of these methods even if the result was reactive.

Conclusions

Availability of HIV self-sampling kits as an additional testing methodology would lead to a much-needed increase of testing frequency, especially for the hidden, high-risk, and undertested GBMSM population. Online-based technologies without any personal interaction were preferred for the communication of the results, even for reactive results.

Sexual and Mental Health Inequalities across Gender Identity and Sex-Assigned-at-Birth among Men-Who-Have-Sex-with-Men in Europe: Findings from EMIS-2017

Some men who have sex with men (MSM) were assigned female at birth (AFB) and/or identify as trans men. Little is known about how these men differ from other MSM. We compared sexual and mental health indicators from the European MSM Internet Survey (EMIS-2017), comparing men AFB and/or currently identifying as trans men with those assigned male at birth (AMB) who identified as men. EMIS-2017 was an opportunistic 33-language online sexual health survey for MSM recruiting throughout Europe. We used regression models adjusting for age, country of residence and employment status to examine differences across groups. An analytic sample of 125,720 men living in 45 countries was used, of which 674 (0.5%) were AFB and 871 (0.7%) identified as trans men. The two sub-groups were not coterminous, forming three minority groups: AFB men, AFB trans men and AMB trans men. Minority groups were younger and more likely unemployed. Anxiety, depression, alcohol dependence and sexual unhappiness were more prevalent in sex/gender minority men. Conversely HIV and STI diagnoses were less common. AMB trans men were most likely to have sexual risk behavior with steady partners and to have unmet health promotion needs, and were least likely to be reached by interventions. Sex assigned at birth and trans identification were associated with different sexual and mental health needs. To facilitate service planning and to foster inclusion, sex-assigned-at-birth and current gender identity should be routinely collected in health surveys.

Online socializing among men who have sex with men and transgender people in Nairobi and Johannesburg and implications for public health-related research and health promotion: an analysis of qualitative and respondent-driven sampling survey data

INTRODUCTION

There is little published literature about gay, bisexual and other men who have sex with men and transgender individuals (MSM and TG)'s use of social media in sub-Saharan Africa, despite repressive social and/or criminalizing contexts that limit access to physical HIV prevention. We sought to describe MSM and TG's online socializing in Nairobi and Johannesburg, identifying the characteristics of those socializing online and those not, in order to inform the development of research and health promotion in online environments.

METHODS

Respondent-driven sampling surveys were conducted in 2017 in Nairobi (n = 618) and Johannesburg (n = 301) with those reporting current male gender identity or male sex assigned at birth and sex with a man in the last 12 months. Online socializing patterns, sociodemographic, sexual behaviour and HIV-testing data were collected. We examined associations between social media use and sociodemographic characteristics and sexual behaviours among all, and only those HIV-uninfected, using logistic regression. Analyses were RDS-II weighted. Thirty qualitative interviews were conducted with MSM and TG in each city, which examined the broader context of and motivations for social media use.

RESULTS

Most MSM and TG had used social media to socialize with MSM in the last month (60% Johannesburg, 71% Nairobi), mostly using generic platforms (e.g. Facebook), but also gay-specific (e.g. Grindr). HIV-uninfected MSM and TG reporting riskier recent sexual behaviours had raised odds of social media use in Nairobi, including receptive anal intercourse (adjusted OR = 2.15, p = 0.006), buying (aOR = 2.24, p = 0.015) and selling sex with men (aOR = 2.17, p = 0.004). Evidence for these associations was weaker in Johannesburg, though socializing online was associated with condomless anal intercourse (aOR = 3.67, p = 0.003) and active syphilis (aOR = 13.50, p = 0.016). Qualitative findings indicated that while online socializing can limit risk of harm inherent in face-to-face interactions, novel challenges were introduced, including context collapse and a fear of blackmail.

CONCLUSIONS

Most MSM and TG in these cities socialize online regularly. Users reported HIV acquisition risk behaviours, yet this space is not fully utilized for sexual health promotion and research engagement. Effective, safe and acceptable means of using online channels to engage with MSM/TG that account for MSM and TG's strategies and concerns for managing online security should now be explored, as complements or alternatives to existing outreach.

An exploratory assessment of the preference for eHealth interventions to prevent HIV and sexually transmitted infections among men who have sex with men in Hanoi, Vietnam

BACKGROUND

Electronic health (eHealth) interventions are promising in HIV and sexually transmitted infections (STIs) prevention among men who have sex with men (MSM), given a high rate of the Internet use in this population. This study determined the preferences for eHealth interventions to prevent HIV and STIs among MSM in Hanoi, Vietnam to guide the development of future eHealth interventions.

METHODS

Five focus group discussions (FGD) were conducted with 35 MSM recruited by purposive sampling in January 2018 in Hanoi, Vietnam. The FGDs addressed attitudes towards the feasibility and uptake of HIV/STI interventions via online modalities such as smartphone applications (apps, social network sites, or emails); preferences and concerns regarding an online HIV/STI intervention. FGDs were audio-recorded and transcribed verbatim. Content analysis was used to determine themes.

RESULTS

MSM reported that they commonly searched for information regarding HIV/STI and sexual health on Facebook and a variety of mobile apps. They perceived a lack of reliable online sources, a high need, and interest for an online intervention. Most of them preferred short and concise messages without perceived sensitive words such as "HIV" or "STI". Diversity of online modalities were preferred with information from credible sources about HIV/STI symptoms, testing and treatment, safe sex practices and testing locations with a focus on safe MSM-friendly clinics. Concerns about the need to trust the organization behind the online information and interventions, and the importance of confidentiality when participating in online interventions were raised.

CONCLUSION

High acceptance and perceived need for an online HIV/STI intervention were reported. The importance of establishing trust within the MSM community as a reliable source of information was emphasized, as well as the importance of confidentiality.

High risk men who have sex with men in Spain are reporting low intentions of actively seeking HIV testing: results from a cross-sectional study

Background

We analyse unprotected anal intercourses (UAI) self-reported by a sample of men who have sex with men (MSM), by their future testing intentions and past testing history to identify undertested subpopulations that could be contributing to onward transmission.

Methods

We recruited MSM through gay dating websites in Spain from September 2012 to April 2013. For MSM at risk of acquiring or unknowingly transmitting HIV (at risk hereafter) we calculate time at risk, number of UAI in the last 12 months and last 5 years by testing intention (low intention (LI), Medium intention (MI), high intention (HI)) and past testing history. For never testers we analyse the reasons for not having been tested.

Results

Of 3272 MSM at risk, 19.8% reported LI of testing. MSM with LI reported the longest period at risk (8.49 years (p < 0.001)) and reported 3.20 UAI/person in the last 12 months (vs. 3.23 and 2.56 in MSM with HI and MI (p < 0.001)) and 12.90 UAI/person in the last 5 years (vs. 8.07 and 9.82 in MSM with HI and MI (p < 0.001)). Those with LI accounted for 21 and 27% of all the UA acts occurring in the last 12 months and the last 5 years. Among never testers (40.6%), those with LI reported lower risk perception (p = 0.006).

Conclusion

We identified a group of high risk and undertested MSM that could be behind a substantial proportion of the UAIs with potential of transmission/acquisition of HIV. Given their low willingness to seek an HIV test and low risk perception, they constitute a population that will probably require approaches other than client initiated strategies.

Are PrEP services in France reaching all those exposed to HIV who want to take PrEP? MSM respondents who are eligible but not using PrEP (EMIS 2017)

Pre-exposure prophylaxis (PrEP) is fully reimbursed by the French health insurance system since 2016. However, uptake of PrEP is slower than expected and little is known about men who have sex with men (MSM) who are eligible for PrEP according to French guidelines, but not using it. This study aims to (1) assess and describe MSM that are eligible to PrEP but not using it, and (2) identify potential individual and structural barriers of PrEP uptake among eligible MSM who are aware and intend to take PrEP. Data from EMIS-2017, a cross-sectional internet survey among gay, bisexual, and other MSM, were used. Among 7965 respondents without diagnosed HIV, 9.2% were PrEP users. Among 7231 non-PrEP users, 35.2% were eligible to PrEP and 15.2% were eligible, aware and intended to take PrEP. Eligible MSM who are not using PrEP are mostly younger, students, less "out", living in small cities, using condoms more frequently but still with low self-efficacy regarding safe sex and more distant from preventive health care and information than PrEP users. Despite free PrEP availability in France, results suggest that PrEP is not fully accessible and that there is a need to increase PrEP demand and decentralize PrEP delivery.

Characteristics and sexual health service use of MSM engaging in chemsex: results from a large online survey in England

Background

Chemsex, the use of select psychoactive drugs to enhance sexual experience, typically among men who have sex with men (MSM), is associated with sexual behaviours with higher STI risk. Understanding patterns of chemsex among MSM as well as the characteristics and sexual health service engagement of chemsex participants is important for developing interventions.

Methods

Between 5/2016 to 5/2017, 3933 MSM completed an online survey, recruited in sexual health clinics (SHCs) in England (n=421) and via four social networking/dating apps (n=3512). We described patterns of chemsex in the past year and used multivariable logistic regression to investigate differences in demographics and sexual behaviours by chemsex history. We described history of SHC attendance and STI test in the past year among app-recruited chemsex participants.

Results

Chemsex in the past year was reported by 10% of respondents; 19% of SHC-recruited and 9% of app-recruited. Among chemsex participants, 74% had used ≥2 chemsex drugs. In the multivariable model, MSM engaging in chemsex had a raised odds of being HIV-positive (adjusted OR (aOR): 3.6; 95% CI 2.1 to 6.1), aged 30–44 (aOR 1.5 vs <30 years; 95% CI 1.0 to 2.1), being born outside the UK and having engaged in higher risk sexual behaviours in the past 3 months. Chemsex participants also had higher odds of condomless anal sex with partners of different or unknown HIV status, but only among HIV-negative/untested. In the past year, 66% of app-recruited chemsex participants had attended a SHC and 81% had had an STI test.

Conclusion

One in 10 MSM recruited through community and clinical settings across England had engaged in chemsex in the past year. Those that did appear to be at greater STI risk but engaged more actively with sexual health services. This highlights the need and opportunity for chemsex-related services in SHCs and robust referral pathways to drug treatment services.

Scaling up screening and treatment for elimination of hepatitis C among men who have sex with men in the era of HIV pre-exposure prophylaxis

BACKGROUND

Routine HIV pre-exposure prophylaxis (PrEP) and HIV care appointments provide opportunities for screening men who have sex with men (MSM) for hepatitis C virus infection (HCV). However, levels of screening required for achieving the WHO elimination target of reducing HCV incidence by 90% by 2030 among all MSM are unknown.

METHODS

An HCV/HIV transmission model was calibrated to UK prevalence of HIV among MSM (4·7%) and chronic HCV infection among HIV-positive MSM (9·9%) and HIV-negative MSM (1.2%). Assuming 12·5% coverage of PrEP among HIV-negative MSM, we evaluated the relative reduction in overall HCV incidence by 2030 (compared to 2018 levels) of HCV screening every 12/6-months (alongside completing direct acting antiviral treatment within 6-months of diagnosis) in PrEP users and/or HIV-diagnosed MSM. We estimated the additional screening required among HIV-negative non-PrEP users to reduce overall incidence by 90% by 2030. The effect of 50% reduction in condom use among PrEP users (risk compensation) was estimated.

RESULTS

Screening and treating PrEP users for HCV every 12 or 6-months decreases HCV incidence by 67·3% (uncertainty range 52·7-79·2%) or 70·2% (57·1-80·8%), respectively, increasing to 75·4% (59·0-88·6%) or 78·8% (63·9-90·4%) if HIV-diagnosed MSM are also screened at same frequencies. Risk compensation reduces these latter projections by <10%. To reduce HCV incidence by 90% by 2030 without risk compensation, HIV-negative non-PrEP users require screening every 5·6 (3·8-9·2) years if MSM on PrEP and HIV-diagnosed MSM are screened every 6-months, shortening to 4·4 (3·1-6·6) years with risk compensation. For 25·0% PrEP coverage, the HCV elimination target can be reached without screening HIV-negative MSM not on PrEP, irrespective of risk compensation.

INTERPRETATION

At low PrEP coverage, increased screening of all MSM is required to achieve the WHO HCV-elimination targets for MSM in the UK, whereas at higher PrEP coverage this is possible through just screening HIV-diagnosed MSM and PrEP users.

Who Do You Reach? A Norwegian Pilot Project on HIV Self-Testing that Targeted Men Who Have Sex with Men

HIV self-testing reduces barriers associated with other HIV testing services, such as concerns about confidentiality and inconvenience. This article demonstrates who might benefit from this approach to HIV testing by describing the characteristics of men who have sex with men (MSM) who took interest in a Norwegian pilot project on HIV self-testing. Of the MSM users, 27% reported that they had never been tested for HIV. Not disclosing one's same-sex sexuality, particularly among non-gay-identified MSM, was associated with a higher probability of never having been tested for HIV and choosing to test with an HIV self-test because of its anonymity. Never having been tested for HIV was also associated with a higher probability of choosing to test with an HIV self-test due to anonymity. The results suggest that the HIV self-tests' ability to reach MSM who otherwise would not be tested is partly because it is an anonymous HIV testing alternative.

Low levels of chemsex among men who have sex with men, but high levels of risk among men who engage in chemsex: analysis of a cross-sectional online survey across four countries

Background This paper establishes the prevalence of chemsex drug use among men who have sex with men (MSM), the extent to which these drugs are used in a sexual context, as well as their associated behaviours and circumstances of use.

METHODS

Data from a cross-sectional, online survey of 2328 MSM recruited via gay sociosexual media in Scotland, Wales, Northern Ireland and the Republic of Ireland were analysed.

RESULTS

While almost half (48.8%) of participants had ever taken illicit drugs, lifetime chemsex drug use was less common (18.0%) and far fewer reported chemsex drug use in the last year (8.2%) or last 4 weeks (3.0%). Just over one-quarter (27.1%) of men who used chemsex drugs in the last year reported no sexualised drug use, but almost three-quarters (72.9%) did. Only 6.1% of the whole sample reported sexualised chemsex drug use in the last year. The odds of reporting chemsex in the last year were significantly higher for men aged 36-45 years (AOR=1.96), single men (AOR=1.83), men who were HIV positive (AOR=4.01), men who report high-risk sex (AOR=4.46), being fisted (AOR=7.77) or had sex in exchange for goods other than money (AOR=4.7) in the last year and men who reported an HIV test in the last 3 months (AOR=1.53).

DISCUSSION

Only a small proportion of MSM in Scotland, Wales, Northern Ireland and the Republic of Ireland reported chemsex, and, for the first time, it is demonstrated that not all chemsex drug use was sexualised. Nevertheless, MSM who engage in chemsex (MWEC) reported substantial sexual risk inequalities. These novel findings highlight several opportunities for intervention, particularly around the multiple vulnerabilities of MWEC, opportunities for early identification of those most vulnerable to chemsex-related harm and the potential to develop a specialised responsive patient pathway.

Agent-based modelling study of antimicrobial-resistant Neisseria gonorrhoeae transmission in men who have sex with men: towards individualised diagnosis and treatment

Background Antimicrobial-resistant (AMR) gonorrhoea is a global public health threat. Discriminatory point-of-care tests (POCT) to detect drug sensitivity are under development, enabling individualised resistance-guided therapy.

METHODS

An individual-based dynamic transmission model of gonorrhoea infection in MSM living in London has been developed, incorporating ciprofloxacin-sensitive and resistant strains. The time-dependent sexual contact network is captured by periodically restructuring active connections to reflect the transience of contacts. Different strategies to improve treatment selection were explored, including discriminatory POCT and selecting partner treatment based on either the index case or partner susceptibility. Outcomes included population prevalence of gonorrhoea and drug dose counts.

RESULTS

It is shown that using POCT to detect ciprofloxacin-sensitive infections could result in a large decrease in ceftriaxone doses (by 70% compared with the reference case in the simulations of this study). It also suggests that ceftriaxone use can be reduced with existing technologies, albeit to a lesser degree; either using index case sensitivity profiles to direct treatment of partners, or testing notified partners with strain discriminatory laboratory tests before treatment, reduced ceftriaxone use in our model (by 27% and 47% respectively).

CONCLUSIONS

POCT to detect ciprofloxacin-sensitive gonorrhoea are likely to dramatically reduce reliance on ceftriaxone, but requires the implementation of new technology. In the meantime, the proportion of unnecessary ceftriaxone treatment by testing partners before treatment could be reduced significantly. Alternatively, index case sensitivity profiles could be used to select effective treatments for partners.

A Systematic Review of eHealth Interventions Addressing HIV/STI Prevention Among Men Who Have Sex With Men

A systematic review was conducted to summarize and appraise the eHealth interventions addressing HIV/STI prevention among men who have sex with men (MSM), and characterize features of successful eHealth interventions. Fifty-five articles (17 pilots and 38 full efficacy trials) were included with the predominance of web-based interventions in the United States-based settings. Intervention modalities include web-based, short message service (SMS)/text messges/email reminder, online video-based, computer-assisted, multimedia-based, social network, live chat and chat room, virtual simulation intervention, and smartphone applications. Forty-nine eHealth interventions achieved a short-term behaviour change among participants. Four studies were conducted with 12-month follow-ups; and only one of them could maintain the behaviour change over this longer time period which could be due to the lack of booster interventions. Our study suggests that eHealth interventions can achieve short term behaviour change among MSM, however limited interventions could maintain behaviour change over 12 months. Further eHealth intervention strategies to promote HIV prevention among MSM should be conducted and rigorously evaluated.

Pilot phase of an internet-based RCT of HIVST targeting MSM and transgender people in England and Wales: advertising strategies and acceptability of the intervention

BACKGROUND

The SELPHI study (An HIV Self-Testing Public Health Intervention) is an online randomised controlled trial (RCT) of HIV self-testing (HIVST). The aim of this study was to assess the feasibility of recruiting UK men who have sex with men (cis and trans) and trans women who have sex with men to the SELPHI pilot, and the acceptability of the HIVST intervention used among those randomised to receive a kit.

METHODS

A mixed-methods approach to assessing trial feasibility and intervention acceptability was taken, using quantitative data from advertising sources and RCT surveys alongside qualitative data from a nested sub-study.

RESULTS

Online recruitment and intervention delivery was feasible. The recruitment strategy led to the registration of 1370 participants of whom 76% (1035) successfully enrolled and were randomised 60/40 to baseline testing vs no baseline testing. Advertising platforms performed variably. Reported HIVST kit use increased from 83% at two weeks to 96% at three months. Acceptability was very high across all quantitative measures. Participants described the instructions as easy to use, and the testing process as simple. The support structures in SELPHI were felt to be adequate. Described emotional responses to HIVST varied.

CONCLUSIONS

Recruiting to a modest sized HIVST pilot RCT is feasible, and the recruitment, intervention and HIVST kit were acceptable. Research on support needs of individuals with reactive results is warranted.

Combination prevention and HIV: a cross-sectional community survey of gay and bisexual men in London, October to December 2016

BackgroundMen who have sex with men (MSM) are at risk of HIV and are an important population to monitor and ameliorate combination prevention efforts.AimTo estimate HIV prevalence and identify factors associated with frequent HIV testing (≥ 2 HIV tests in the last year) and pre-exposure prophylaxis (PrEP) use among MSM in London.MethodsFor this cross-sectional study, MSM recruited from 22 social venues provided oral-fluid samples for anonymous HIV antibody (Ab) testing and completed a questionnaire. Factors associated with frequent HIV testing and PrEP use were identified through logistic regression.ResultsOf 767 men recruited, 545 provided an eligible oral specimen. Among these, 38 MSM (7.0%) were anti-HIV positive including five (13.2%; 5/38) who reported their status as negative. Condomless anal sex within the previous 3 months was reported by 60.1% (412/685) men. Frequent HIV testing was associated with, in the past year, a reported sexually transmitted infection (adjusted odds ratio (AOR): 5.05; 95% confidence interval (CI): 2.66-9.58) or ≥ 2 casual condomless partners (AOR 2-4 partners: 3.65 (95% CI: 1.87-7.10); AOR 5-10 partners: 3.34(95% CI: 1.32-8.49). Age ≥ 35 years was related to less frequent HIV testing (AOR 35-44 years: 0.34 (95% CI: 0.16-0.72); AOR ≥ 45 years: 0.29 (95% CI: 0.12-0.69). PrEP use in the past year was reported by 6.2% (46/744) of MSM and associated with ≥ 2 casual condomless sex partners (AOR: 2.86; 95% CI: 1.17-6.98) or chemsex (AOR: 2.31; 95% CI: 1.09-4.91).ConclusionThis bio-behavioural study of MSM found high rates of behaviours associated with increased risk of HIV transmission. Combination prevention, including frequent HIV testing and use of PrEP, remains crucial in London.

Preferences for HIV testing services among men who have sex with men in the UK: A discrete choice experiment

BACKGROUND

In the UK, approximately 4,200 men who have sex with men (MSM) are living with HIV but remain undiagnosed. Maximising the number of high-risk people testing for HIV is key to ensuring prompt treatment and preventing onward infection. This study assessed how different HIV test characteristics affect the choice of testing option, including remote testing (HIV self-testing or HIV self-sampling), in the UK, a country with universal access to healthcare.

METHODS AND FINDINGS

Between 3 April and 11 May 2017, a cross-sectional online-questionnaire-based discrete choice experiment (DCE) was conducted in which respondents who expressed an interest in online material used by MSM were asked to imagine that they were at risk of HIV infection and to choose between different hypothetical HIV testing options, including the option not to test. A variety of different testing options with different defining characteristics were described so that the independent preference for each characteristic could be valued. The characteristics included where each test is taken, the sampling method, how the test is obtained, whether infections other than HIV are tested for, test accuracy, the cost of the test, the infection window period, and how long it takes to receive the test result. Participants were recruited and completed the instrument online, in order to include those not currently engaged with healthcare services. The main analysis was conducted using a latent class model (LCM), with results displayed as odds ratios (ORs) and probabilities. The ORs indicate the strength of preference for one characteristic relative to another (base) characteristic. In total, 620 respondents answered the DCE questions. Most respondents reported that they were white (93%) and were either gay or bisexual (99%). The LCM showed that there were 2 classes within the respondent sample that appeared to have different preferences for the testing options. The first group, which was likely to contain 86% of respondents, had a strong preference for face-to-face tests by healthcare professionals (HCPs) compared to remote testing (OR 6.4; 95% CI 5.6, 7.4) and viewed not testing as less preferable than remote testing (OR 0.10; 95% CI 0.09, 0.11). In the second group, which was likely to include 14% of participants, not testing was viewed as less desirable than remote testing (OR 0.56; 95% CI 0.53, 0.59) as were tests by HCPs compared to remote testing (OR 0.23; 95% CI 0.15, 0.36). In both classes, free remote tests instead of each test costing £30 was the test characteristic with the largest impact on the choice of testing option. Participants in the second group were more likely to have never previously tested and to be non-white than participants in the first group. The main study limitations were that the sample was recruited solely via social media, the study advert was viewed only by people expressing an interest in online material used by MSM, and the choices in the experiment were hypothetical rather than observed in the real world.

CONCLUSIONS

Our results suggest that preferences in the context we examined are broadly dichotomous. One group, containing the majority of MSM, appears comfortable testing for HIV but prefers face-to-face testing by HCPs rather than remote testing. The other group is much smaller, but contains MSM who are more likely to be at high infection risk. For these people, the availability of remote testing has the potential to significantly increase net testing rates, particularly if provided for free.

Effects of Multiple Forms of Information Bias on Estimated Prevalence of Suicide Attempts According to Sexual Orientation: An Application of a Bayesian Misclassification Correction Method to Data From a Systematic Review

Multiple epidemiologic studies demonstrate a disparity in suicide risk between sexual minority (lesbian, gay, bisexual) and heterosexual populations; however, both "exposure" (sexual minority status) and outcome (suicide attempts) may be affected by information bias related to errors in self-reporting. We therefore applied a Bayesian misclassification correction method to account for possible information biases. A systematic literature search identified studies of lifetime suicide attempts in sexual minority and heterosexual adults, and frequentist meta-analysis was used to generate unadjusted estimates of relative risk. A Bayesian model accounting for prior information about sensitivity and specificity of exposure and outcome measures was used to adjust for misclassification biases. In unadjusted frequentist analysis, the relative risk of lifetime suicide attempt comparing sexual minority with heterosexual groups was 3.38 (95% confidence interval: 2.65, 4.32). In Bayesian reanalysis, the estimated prevalence was slightly reduced in heterosexual adults and increased in sexual minority adults, yielding a relative risk of 4.67 (95% credible interval: 3.94, 5.73). The disparity in lifetime suicide attempts between sexual minority and heterosexual adults is greater than previously estimated, when accounting for multiple forms of information bias. Additional research on the impact of information bias in studies of sexual minority health should be pursued.

A Systematic Review and Meta-Analysis of Disparities in the Prevalence of Suicide Ideation and Attempt Among Bisexual Populations

Sexual minorities are at increased risk of suicide; however, it is unclear whether there are within-sexual minority differences in risk across specific sexual identities-notably between bisexual and lesbian/gay subgroups. We therefore conducted a systematic review and meta-analysis to quantify associations between bisexual identity and self-reported suicide ideation and attempt and the moderation of these associations by gender/sex, age, sampling strategy, and measurement of sexuality. Abstracts and full texts were independently screened by two reviewers, resulting in a total of 46 studies that met inclusion criteria and reported 12-month or lifetime prevalence estimates for suicide ideation or attempt. A consistent gradient was observed across all four outcomes, whereby bisexual respondents reported the highest proportion of suicide ideation or attempt, lesbian/gay respondents the next highest proportion, and heterosexual respondents the lowest proportion. Random-effects meta-analysis comparing bisexual individuals with lesbian/gay individuals yielded odds ratios (ORs) ranging between 1.22-1.52 across the four outcomes examined. Between-study variability in ORs was large. Thirty-one percent of heterogeneity was explained by sample type (e.g., probability vs. non-probability) and 17% by gender/sex. ORs were consistently larger for women (range: 1.48-1.95, all statistically significant at p < .05) than for men (range: 1.00-1.48, all p > .05), suggesting that gender/sex moderates the association between bisexual identity and suicide risk. Within-sexual minority differences in suicide risk may be attributed to structural and interpersonal experiences of monosexism, bisexual erasure and invisibility, or lack of bisexual-affirming social support, each of which may be experienced differently across gender/sex identities.